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John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Back in April, Evan Steele, CEO of SRSsoft, wrote an interesting post about EMR adoption and he asked the question, “Why Are You Still on the Fence?” It’s a very good question. Plus, he adds some value to the conversation by listing some of the problems with paper charts versus an EMR. Here’s a section of his post:

So why are these physicians, who have determined that government incentives are not relevant or achievable, still on the fence about adopting an EMR solution that will deliver measurable benefits? Staying with paper charts is not a good business strategy because there is nothing more inefficient!

The costs associated with the excess staff needed to manage these medical records are massive and wasteful—these positions can be eliminated or the employees can be more effectively used in revenue-generating or patient-care roles.

Paper charts hinder practice growth because adding physicians requires a proportional increase in support staff—medical records, billing, nurses, and medical assistants—and because physicians can’t see more patients without lengthening their work hours.

Profitability is further affected by billing bottlenecks that delay revenue collection.

The chaos associated with trying to manage paper charts has a damaging effect on staff morale and creates rampant frustration among patients, physicians, and staff.

Paper charts are a malpractice nightmare—prescriptions are not consistently documented, orders are not easily tracked, and medical decisions are often made without complete clinical information.

So, why are doctors on the fence with EMR? The sad thing for me was the pre-EMR stimulus money, I felt a shift in the tone of conversation around EMR adoption. Doctors had mostly moved from wondering if they should implement an EMR to how they should implement an EMR and which EMR they should implement. They were off of the fence and I saw the tide shifting.

And then in one anti-stimulative swoop, the HITECH act rolled out and doctors decided to go back to the sidelines and see this government incentive play out. Now they’re waiting for meaningful use to be defined. While the HITECH act has increased EMR awareness 10 fold, it’s also done much damage on the short term EMR adoption. I’m not sure that the increased awareness will overcome the damage that it’s caused.

Of course, the damage is done and so we have to go forward from here. I suggest we go back to pre-EMR stimulus times and focus more effort back on the benefits of EMR and the costs of paper instead of the government handouts. If we do that, we’ll see a fantastic shift to more widespread EMR adoption.

10 responses to "Think About the Problems with Paper Charting"

“Why are doctors on the fence?” I don’t know, have you asked them? It doesn’t sound like you have. A few years ago a doc told me he wouldn’t use an EMR if you paid him. Well now he is being paid and guess what. They don’t give a darn about HITECH or meaningful use.

Doctors are not technology laggards. They use technology that works and they eschew technology that doesn’t. EMR to date has caused more problems and introduced more error than it has prevented. The work flow is just not conducive to point-and-click. If EMR worked, do you really think we’d have to pay them to use it?

Brian,
I think that the interest in the EMR stimulus says otherwise. I wish you were right that “They don’t give a darn about HITECH or meaningful use.” The facts just show otherwise.

As far as not adopting EMR because they don’t work, I agree with you 4-5 years ago. That’s why I mentioned the shift in attitude. For exactly the reasons you mentioned. Doctors were seeing the value of the EMR as they’d matured. Then, the EMR stimulus came and no one can talk about anything else.

Good points. It does seem like the stimulus factor has made money the first part of the EMR decision for many. But one positive outcome of the stimulus is that it is increasing the volume of discussion about EMR software implementation.

The reason docs(and nurses and admins) might be seen as still ‘on the fence’ is that the field of EMR software has exploded and that the decisions that might have easily been made 3 years ago are much more difficult now with the greater number of vendors from which to choose.

Some docs (like my client) have also had bad experiences with EMR software in the past, and are weary about making the same mistakes.

I would just observe that, absent significant payment reform (I won’t be holding my breath), there’s a very real problematic barrier to effective EHR use if we don’t change the basic paradigm. For example, fundamental to the concept of the “patient-centered medical home” trial initiatives now getting underway is the argument that primary care docs should properly be seeing no more than 8-10 patients per day (e.g., think about the typical hour attorney consult visit), that the customary 25-30 pts/day is driven by the need to bill, to keep the doors open; that roughly half of outpatient visits are of marginal to nil clinical value.

I and one of my REC colleagues did a clinic assessment visit the other day. We interviewed 4 docs, one of whom was a severe Dr. NO!” on the topic of HIT. His beef was basically a “productivity loss” complaint, i.e. that seeing mostly older, complex problem list pts (he’s Internal Med) made it nigh impossible to effectively chart electronically in within the scheduling constraint.

Now, perhaps with a lighter, more rational daily patient load (and more extensive EHR training) he might come around and truly “adopt.”

I consulted with an attorney a couple of years ago regarding legal guardianship over my dementia-addled (now late) Dad. The initial hour cost me $300. The entire deal ended up costing about $4,000.

A physician, however, is supposed to take in myriad data and make a comparably expert decision in 15-30 minutes — and hope he/she can eventually get reimbursed a relative pittance.

It’s crazy.

So, OK, where are we? We’re facing a current and projected shortage of perhaps 40-50,000 primary care docs, and under PCMH theory we propose to cut their pt volumes in HALF ore more so they can provide better care? All while bringing tens of thousands of the previously uninsured into the (non-ER) system under Obamacare reform.

Right.

I don’t have a good answer for the skeptical docs who argue that the EMR gold rush is more about billing imperatives and vendor welfare, that the docs’ pt care-analytic needs are a distant 3rd at best.

You can read my short response at the end of the post. Although, I think it is very interesting to link the payment methodologies and how they impact EMR adoption. That’s why I think looking at other countries EMR implementations are so interesting.

Let’s see, McDonalds and FedEx and UPS and Fidelity and State Farm and every other industry under the sun uses technology and automation why? ’cause it’s sexy?
No.
It saves money, improves the client experience, improves service delivery and reduces errors.
Make a mistake with a burger order? maybe you have to make another burger. Make a drug interaction error or omit/ignore a key allergy? kill somebody.
There have been well over a million jobs created in healthcare since 2001, and they aren’t doctors and nurses, they are paper-pushers and administrative staff.
Old doctors hate EMR and won’t adopt. Young doctors, residents and interns, when they go into a practice and confront clipboards and paper charts, are aghast.
This is not a technical problem. It’s not even an economic problem.

The problem isn’t with the technology.. it is with the people. Specifically, two areas: 1) a staff knows the doctor’s shorthand and can interpret, infer and even in rare cases completely replace what the doctor has written when transcribing (yes, I’ve been in offices where the person at checkout .. types everything up from the charge sheet, runs spell check, sends it to the laser printer and then picks up, punches and puts in the chart).

When you move to an EMR, you are pretty much stuck using the terms the EMR understands.. learning curve, which people typically dispise.. so much so that even being told to RTFM .. people don’t.

If the EMR was really well designed (I’ve yet to hear of one), it would allow for all the local jargon to be defined to the system. Thus allowing the EMR data to be used for comparative care studies — initially, limited to within the practice and later on a broader base.

2) doctors and administrators are people too. Improve efficiency significantly enough and you reach a point where you have to release employees. No one likes releasing staff, who might also be friend, when the only reason is the office is more efficient.

Mike,
There are some EMR systems that incorporate the local jargon. The problem is that it becomes too complex for a computer to manipulate. Usually it’s not a straight one to one scenario. It’s a one to many depending on other factors.

Thank you for all your comments. We have several clients who use us to help scan their medical records and we have had several prospects who are leaving the documents in boxes. It’s been an interesting journey and it seems that the stimulus money has created more resistance. Thanks again for the comments and all the great wise information

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